Accomplishments and Challenges in Medicaid Mental Health Services Innovation, Financing and Change June 5, 2008 Richard H. Dougherty, Ph.D.
Accomplishments There has been significant reductions in state hospital utilization since its peak in 1955 and dramatic growth in community systems There is increasing recognition of the economic impact of substance abuse and mental disorders Depression is the 4 th leading contributor to the global burden of disease (WHO); Substance abuse has indirect costs of more than $260B in the US (NIH 2000) Significant advances in research and increased treatment efficacy The results of the CATIE study have reshaped thinking about prescribing practice and the Schizophrenia PORT study documented the wide gap between guidelines and practice Growth of recovery and of the consumer movement Growth in the role of family run organizations and communities Increasing focus on interagency collaboration Between Mental Health and Medicaid, Criminal Justice, Schools, Courts, employment, housing and other agencies 2
Innovations Enhancing consumer centered care: Georgia Peer specialists Florida Self-Directed Care Magellan Iowa and others Systems Integration efforts: New Jersey (kids), New Mexico, Washington State Effective use of disease management strategies in Wyoming for depression and schizophrenia Medication Algorithm projects TMAP, CalMAP and increasing numbers of others. Reducing multiple prescribers, poly-pharmacy etc. Process and Quality Improvement initiatives IA, NIATx Performance incentives and financing of evidence based practices KY and Delaware * * http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=392669 3
Positive Movement Increasing recognition of the need to integrate mental health with physical health care services Beginning to address the physical health needs of people with serious mental illness diabetes, heart disease and the impact of smoking There is an increasing effort at the federal level for collaboration between CMS and SAMHSA A long road is ahead Increased recognition of the value of and need for wrap-around services as alternatives to residential and psychiatric placements for children Expanded use of and recognition of the need for and value of family to family and adult peer services: Home based services, respite, peer support, bridgers, and other strategies Increasing though still limited use of performance contracting Increasing focus on evidence and IT to drive practice most notably on prescribing practices, expanded use of EMRs, and adoption of evidence based practices 4
Challenges There is a need for radical change Transformation - and yet resistance throughout the system Most states have very limited competition among providers either through licensing rules, deficit funding strategies or county operated services There are often archaic models of case management In the public sector there are wide gaps between change agents and those resistant to change There is a workforce crisis of educating, training, recruiting and retaining qualified and skilled people There is an extraordinary level of variation in state mental health programs resulting from Agency structure for MHA and Medicaid Child and Adult system structure County role and funding levels Medicaid financing and delivery system Financing methods grants, FFS, Cost reimbursement, etc. Other state Agency Spending Child residential; housing; etc. 5
Financing Challenges State budget limitations have limited funding growth to zero or well below the cost of living in most states Public systems are increasingly reliant on Medicaid funding which is now a majority of public mental health funding New CMS regulations Rehabilitation Option Requires very specific rehab plans Documentation required of progress to goals or changes in plans Billing practices may be significantly changed Targeted Case Management (TCM) Case management limited to treatment planning and referral Other activities life skills, assistance with housing, etc. would need to be billable as another code. Billing in 15 minute increments Blended Rates Most states use some form of blended rate strategy for their Rehab and TCM related claiming Questions linger about residential rate setting for children and adults where per diem rehab (active treatment) rate percentages are developed to exclude the room and board
Variations on Organization and Financing of Mental Health 7
Medicaid Managed Behavioral Health Models No BH benefit MCO MCOMCOMCO State/County No BH benefit MCO MCOMCO State/County/ MBHO Carve-Out - Risk BH ASO Carve-Out with ASO State SMI Carve-Out Medicaid Agency MCO MCO SMHA SMI Only Medicaid State Medicaid/SMHA Regional/County BHO Regional/County BHO Managed Care Organization (HMO) Managed Care Organization (HMO) Managed Care Organization (HMO) Regional/County BHO Regional/County BHO Regional/County BHO s s s s Integrated MCO s Regional/County BHO 8
Massachusetts Public Mental Health System Department of of Mental Health Strategic Planning Framework Draft 12/20/04 UMBC 2007 Strategic Actions Interagency Coordination & System Oversight Purchasing, Licensing & Service Standards Service Quality Evidence Based Svcs. Admin/Mgmt Services Organization DMH Inpt. DMH Case Mgmt Central Office DMH Comm. Based EOHHS Mental Health Authority SMHA Area Office ESP MHBH Employmt Svcs Inpt POS Resid. & Housing DOC HCFP DOE DTA DYS DMR DSS DPH MBHP MBHP Comm & Peer Support ACT Other MCOs MCOs Outpt Lic. Clinicians FFS FFS 7 9
Michigan Public Mental Health System CMS Federal Match State Match General Funds SAMHSA DSH and GF MI Department of Community Health MH/SA Administration Health Plans MH Benefit 20 Outpt.visits; No Inpt. Psych Pharmacy Carve-Out (reconciled to Health Plans - Capitation Payments for Medicaid - GR - Block Grant 10% County Match GF and POS State Hospital County MH Program Many are Prepaid Inpatient Health Plans; Many Counties are Consolidating 10
California CMS Federal Match General Funds SAMHSA State Match Health Plans Psych Pharmacy Carve-Out (FFS) for Anti-Psychotics County Funds CA Dept. of Health Services Medi-Cal Billing* ISA County MH Program CA Department of Mental Health MHSA funding Global Budgets for Medi-Cal -Short Doyle Medi-Cal DSH and GF State Hospital * Medi-Cal Billing by Counties is for 50% Federal Share only. Counties have the match. County EPSDT spending is 90% matched by state and federal 11
Pennsylvania CMS Federal Match State Match General Funds SAMHSA Physical Health $ MH Funds Medical Assistance State Office of Mental Health Health Plans Psych Pharmacy Health Choices County Capitation Rates - Experience-based - Surplus rolls over with reinvestment plan; - Reserve requirements County Allocation Grants Adult/Child - GF; PATH; Other Grants County MH Programs Health Choices: County Right of First Opportunity: Capitation FFS (MA) Closure Funds State Hospitals County Funds? 12
New Mexico Before After 13
Children s Mental Health Overlapping Populations Schools Children with Disabilities Mental Health Authority Children with SED Incarcerated Children Foster Children Income Eligible Children Juvenile Justice Agency Child Welfare Agency Separate SCHIP Programs Medicaid and SCHIP Expansion 14
Other Agency Spending on Mental Health Mental illnesses, like substance use disorders, have an extraordinary impact across all sectors of government While state Mental Health Authority and Medicaid spending have been a focus for much research, the growing use of prisons for people with mental illness and disruption in schools and communities have focused attention on spending and utilization in other agencies. NASMHPD Research Institute: Other State Agency Study began in 2004 and expanded with a second round of states in 2006. This focus on Other State Agencies is in fact a major focus for SAMHSA Transformation Grants Fiscal Year 2002: Total Mental Health Spending Estimates Rhode Island OTHER $49,764,017 DHS Medicaid RIte Care $16,823,493 DCYF (Includes DCYF Medicaid) $101,624,165 $252,474,659 DMHRH (Includes DMHRH Medicaid) DMHRH $83,262,984 DOC $1,000,000 School Based Health Centers N/A 15
Conclusion In 1972 Medicaid covered about 24% of people with SPMI; by 1998 that population was 60%. 20% are uninsured.* Treatment is but one of the major challenges faced by people with serious mental illnesses. Poverty and unemployment are huge issues SSI and SSDI are mainstays of life for people with severe mental illness but they are insufficient to pay the cost of housing* Vocational training and employment support and accommodations are needed Rehabilitation and support services, however they are financed, are essential to the recovery of people with serious mental illness Community prevention and early intervention with trauma informed treatment hold promise for reducing incidence of some conditions Perhaps the largest challenge is the ongoing stigma faced by people with mental illness in their communities and in society * Frank and Glied Better but not Well (2007) 16
Thank you. Richard H. Dougherty, Ph.D. 9 Meriam St. Suite 4 Lexington, MA 02420 781-863-8003 www.dmahealth.com 17